Meaningful Use Stage Three

AAFP Demands Physician-Friendly MU Rules

The AAFP pulled out all the stops recently in its ongoing effort to make CMS' meaningful use stage three regulation acceptable to already overburdened family physicians.

In response to the proposed ruled, published in the March 30 Federal Register,(www.gpo.gov) AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., highlighted the good, the bad and the downright ugly portions of the rule that is supposed to help family physicians use their electronic health record (EHR) systems to take better care of their patients.

In the May 26 letter(5 page PDF) to CMS Acting Administrator Andrew Slavitt, Blackwelder wasted no time in pressing the agency to delay the implementation of meaningful use stage three until the nation's transition to value-based payment was on firmer ground.

Blackwelder said the AAFP had "grave concern" that the projected timing of stage three was on a collision course with the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), as well as the Merit-based Incentive Payment System (MIPS) that will be developed at the federal level.

Story Highlights

The AAFP pressed for a delay in implementation of meaningful use stage three until the nation's transition to value-based payment was on firmer ground.

Blackwelder punched back hard on a number of items, including the program's "all-or-nothing" nature, the complexity of rules in the three different stages, and program auditors who look for infractions that penalize well-intentioned physicians.

He called for CMS to delay stage three until

MIPS regulations have been implemented,

requirements associated with both MIPS and meaningful use stage three have been harmonized, and

the levels of functionality and interoperability of health information technology products have progressed enough to support the value-based payment needs of family medicine practices.

"Current health IT does not yet have the interoperability required to support value-based payment nor the functionality to be efficient and effective in this new paradigm," said Blackwelder.

Regarding the various stages, the AAFP remained "concerned with the limited timeframe and current challenges impeding successful participation" in stages one and two, said Blackwelder. Specifically, the AAFP objected to CMS' plan to reimpose full-calendar-year reporting after 2015.

"This proposal places an enormous burden on all new adopters of EHRs but also those struggling to modernize their practices and meaningfully use an EHR," said Blackwelder.

Instead, he asserted, CMS should reconsider a 90-day attestation period with the expectation that practices would continue to utilize high-functioning EHRs throughout the year.

Furthermore, said Blackwelder, CMS should finalize policy that would allow physicians to progress through the various meaningful use stages as desired, but give them the option to "jump forward to stage three in 2017 and beyond" without mandating that they accelerate their participation in 2018 before they are ready to do so.

AAFP to Spotlight Workload Hidden in Meaningful Use Criteria

In a recent letter to CMS Acting Administrator Andrew Slavitt, AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., noted that the AAFP was "undertaking a study to evaluate each meaningful use criterion" to single out those that actually benefit patient care from those that add nothing but an additional burden to physician practices.

"As part of this study, we have recruited practicing physicians and industrial engineers to break down the high-level requirements into tasks that must be performed by the eligible professional," said Blackwelder.

"This will show the workload hidden in the high-level descriptions of the required criteria," he added.

Stay tuned. Study results should be ready to share in the fall.

Concerning the "all-or-nothing" nature of the overall meaningful use program, Blackwelder punched back hard. He reiterated the AAFP's concerns about complex rules that thousands of family physicians have tried to follow in good faith, only to be targeted by auditors hired to find infractions -- however miniscule -- that then lead to financial penalties.

"The proposed rule discusses and then declines to follow recommendations made by stakeholders for allowing recourse, exceptions and leniencies for a physician or practice encountering difficulties to receive a partial incentive payment or avoid all or some of the meaningful use penalty under certain circumstances," he said.

On the other hand, Blackwelder applauded the direction CMS was headed in its efforts to selectively collect information aimed at improving patient care and "avoid requiring busy work." He also pointed out CMS' intent to harmonize quality measures "across all programs, all payers and all settings" and noted the AAFP's support for that goal.

Blackwelder also addressed the need for stability within the health care system and asked CMS for patience to ensure that medical practices, hospitals, EHR vendors and other stakeholders could catch their breath -- and catch up with -- meaningful use stage three criteria.

On another front, Blackwelder chastised CMS for not adjusting meaningful use penalties "despite recognizing the current challenges" associated with stages one and two. He called on CMS to utilize "discretionary authority to make case-by-case exemptions for significant hardships."

"We encourage CMS to review the growing list of meaningful use appeals as a basis for creating new hardship criteria and understanding the significant investments that practices make -- yet are not recouping," said Blackwelder.

He also urged greater clarity on the issue of teleheath in the realm of meaningful use of EHRs. "In the absence of CMS specificity, the AAFP is concerned that EHR vendors and auditors may use their own discretion and cause needless variation in functionalities and documentation processes," Blackwelder said.

The AAFP also addressed patient engagement and the fact that patients want to access their health records. CMS noted it was inappropriate to charge patients a fee to access their health information using an application programming interface (API) and Blackwelder agreed, but he also strongly encouraged CMS to "specify that vendors should likewise not charge physicians for API functionality." He called on CMS to make an API "optional for providers."

The Academy vehemently objected to CMS' proposed requirement that 25 percent of all unique patients seen by a physician access their health information electronically using APIs.

"Experience suggests 25 percent is not achievable," said Blackwelder, especially given that "APIs are not currently available, and there are no patient-facing applications available using APIs."

"In addition, we have seen the challenge of patient adoption of technology," said Blackwelder, pointing specifically to patients' lackluster response to the opportunity to use secure messaging and patient portals -- a lethargy that led CMS to reduce its thresholds for meeting those criteria in meaningful use stage two.

He advised CMS to closely monitor the integration of API technology into certified EHRs, as well as the availability of patient-facing applications, and to "adjust the thresholds for this requirement accordingly."